By Shu Xiaoyi, Lead Neurophysiotherapist Cognivate Rehabilitation.
Persistent postural perceptual dizziness (PPPD) is a chronic functional vestibular
disorder that demands genuinely interdisciplinary care. It challenges traditional
service boundaries because symptoms sit at the crossroads of vestibular physiology,
cognition, emotion and participation in daily life.
PPPD in brief
PPPD presents as nonspinning dizziness, unsteadiness or “floaty” sensations
occurring on most days for more than three months. Symptoms are typically
aggravated by upright posture, movement and visually complex environments, while
routine vestibular and neurological examinations can be normal. Diagnosis relies on
the 2017 Barany criteria, which require all five criteria to be met and alternative
explanations to be excluded. This constellation means patients often bounce
between ENT, neurology and mental health services without a coherent formulation.
Traumatic brain injury (TBI) is a particularly important trigger, with large cohorts
showing that most TBI-related PPPD follows mild injuries that might initially be
labelled “just concussion”. These patients are more likely to develop persistent,
treatment-resistant dizziness compared with non-TBI PPPD, and often respond poorly to standard vestibular rehabilitation alone. The combination of subtle neurovestibular change, cognitive load, anxiety and social disruption makes PPPD a paradigmatic condition for an interdisciplinary, rather than singlediscipline, approach.
Why interdisciplinary, not just multidisciplinary?
The ACPIVR Framework for Physiotherapists working within Vestibular and Balance System Health Care sets out core capabilities for assessment, diagnosis,
rehabilitation and collaborative working across the dizziness pathway. It emphasises
person-centred communication, detailed history taking, redflag screening, vestibular
and balance assessment, and structured referral into wider services. Yet PPPD rarely
fits neatly into one professional silo: physiotherapists, psychologists, occupational
therapists, speech and language therapists, audiologists and medical teams all hold
pieces of the puzzle.
Interdisciplinary (IDT) working goes beyond colocation or sequential referrals.
Effective PPPD services use shared assessment frameworks, agreed outcome
measures and a single, integrated care plan rather than parallel, uncoordinated
interventions. Evidence suggests coordinated IDT clinics can achieve improvement
rates of around 78%, compared with approximately 53% in more traditional,
single-discipline pathways, particularly in TBI-related PPPD. These gains are driven by consistent messaging, joint goal setting and active management of the psychological and behavioural drivers that maintain dizziness-related disability.
Case example: Complex Vestibular Service
The Cognivate Complex Vestibular Service illustrates what this looks like in practice.
A 53yearold man presented following TBI with diffuse axonal injury, PPPD,
cognitive-communication disorder, anxiety and emotional dysregulation. He lived with persistent dizziness, severe fatigue, mobility limitations and marked cognitive
difficulties, alongside extreme anxiety, depression, loss of confidence, complete
community avoidance, work incapacity and significant family strain.
Rather than fragmenting care, the service built a single IDT pathway. Physiotherapy
led vestibular rehabilitation, balance retraining and graded exposure to visually
challenging environments. Occupational therapy focused on fatigue management,
functional independence and structured reengagement with community tasks such as shopping and crossing roads. Neuropsychology targeted anxiety, postural
hypervigilance and emotional regulation, using cognitive and behavioural strategies
that were actively reinforced across sessions. Speech and language therapy
addressed cognitive-communication skills, enabling participation in complex,
meaningful activities such as preparing and delivering a wedding speech.
Outcomes were clinically and personally significant. Before treatment, the patient
avoided all community settings, could not cross roads safely, had no work capacity
and required constant support. After the IDT programme, he was independently
shopping and attending social events, navigating busy roads safely, travelling solo,
preparing meals and contributing through community volunteering, with enough
confidence to deliver a public speech. Notably, these gains were achieved with fewer
total therapy hours than would be expected from multiple uncoordinated referrals,
because the team worked to one plan, with one point of contact and clear, shared
goals.
Using frameworks to structure PPPD pathways
The ACPIVR framework gives services a common language to design and evaluate
such pathways. Domain 1 (Person-centred care) emphasises communication, shared
decision making and recognition of how dizziness and imbalance affect work,
relationships and identity, all highly relevant in PPPD. Domains 2 and 3 cover history taking, physical assessment, investigations, rehabilitation, prevention and
self-management—mapping closely onto the needs of PPPD populations across
primary, secondary and community care.
For PPPD, psychological and behavioural factors are not an “add-on” but an integral
treatment target. The framework highlights the importance of behaviour-change
methods, motivational interviewing, CBT-informed strategies and social prescribing to support adherence, reduce avoidance and promote long-term self-management. It also stresses collaborative working, onward referral and shared outcome monitoring, encouraging teams to embed tools such as the Dizziness Handicap Inventory and balance confidence scales within routine practice.
Domain 4 (Service and professional development) then encourages services to audit
their pathways, evaluate outcomes and engage with research and education. This is
particularly important for PPPD, where underrecognition, diagnostic delay and
fragmented care remain common, and where emerging evidence is reshaping how
clinicians understand functional vestibular disorders.
Looking ahead
Interdisciplinary PPPD services, especially in community rehabilitation settings, demonstrate that complex post-TBI dizziness can be managed effectively outside
acute hospitals when vestibular, cognitive, emotional and social needs are addressed
together. Frameworks such as ACPIVR offer a roadmap for physiotherapists and
their colleagues to develop the knowledge, skills and attributes required to lead and
contribute to such pathways. The Cognivate case example shows that when teams
work from a shared playbook, patients can move from avoidance and dependency to
meaningful participation and renewed confidence.
As health systems increasingly recognise PPPD as a distinct, disabling but treatable
condition, interdisciplinary, framework-guided services are likely to become central to modern neurorehabilitation and dizziness care.
Reference
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